Vaccination Coverage Among Adults, Excluding Influenza Vaccination — United States, 2013

Vaccinations are recommended throughout life to prevent vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely recommended vaccines and below Healthy People 2020 targets. In October 2014, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2015. With the exception of influenza vaccination, which is recommended for all adults each year, other adult vaccinations are recommended for specific populations based on a person's age, health conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications. To assess vaccination coverage among adults aged ≥19 years for selected vaccines, CDC analyzed data from the 2013 National Health Interview Survey (NHIS). This report highlights results of that analysis for pneumococcal, tetanus toxoid-containing (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines by selected characteristics (age, race/ethnicity,† and vaccination indication). Influenza vaccination coverage estimates for the 2013-14 influenza season have been published separately. Compared with 2012, only modest increases occurred in Tdap vaccination among adults aged ≥19 years (a 2.9 percentage point increase to 17.2%), herpes zoster vaccination among adults aged ≥60 years (a 4.1 percentage point increase to 24.2%), and HPV vaccination among males aged 19-26 years (a 3.6 percentage point increase to 5.9%); coverage among adults in the United States for the other vaccines did not improve. Racial/ethnic disparities in coverage persisted for all six vaccines and widened for Tdap and herpes zoster vaccination. Increases in vaccination coverage are needed to reduce the occurrence of vaccine-preventable diseases among adults. Awareness of the need for vaccines for adults is low among the general population, and adult patients largely rely on health care provider recommendations for vaccination. The Community Preventive Services Task Force and the National Vaccine Advisory Committee have recommended that health care providers incorporate vaccination needs assessment, recommendation, and offer of vaccination into every clinical encounter with adult patients to improve vaccination rates and to narrow the widening racial/ethnic disparities in vaccination coverage.

Vaccinations are recommended throughout life to prevent vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely recommended vaccines (1) and below Healthy People 2020 targets.* In October 2014, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2015 (2). With the exception of influenza vaccination, which is recommended for all adults each year, other adult vaccinations are recommended for specific populations based on a person's age, health conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications (2). To assess vaccination coverage among adults aged ≥19 years for selected vaccines, CDC analyzed data from the 2013 National Health Interview Survey (NHIS). This report highlights results of that analysis for pneumococcal, tetanus toxoid-containing (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines by selected characteristics (age, race/ethnicity, † and vaccination indication). Influenza vaccination coverage estimates for the 2013-14 influenza season have been published separately (3). Compared with 2012 (1), only modest increases occurred in Tdap vaccination among adults aged ≥19 years (a 2.9 percentage point increase to 17.2%), herpes zoster vaccination among adults aged ≥60 years (a 4.1 percentage point increase to 24.2%), and HPV vaccination among males aged 19-26 years (a 3.6 percentage point increase to 5.9%); coverage among adults in the United States for the other vaccines did not improve. Racial/ethnic disparities in coverage persisted for all six vaccines and widened for Tdap and herpes zoster vaccination. Increases in vaccination coverage are needed to reduce the occurrence of vaccine-preventable diseases among adults. Awareness of the need for vaccines for adults is low among the general population, and adult patients largely rely on health care provider recommendations for vaccination. The Community Preventive Services Task Force and the National Vaccine Advisory Committee have recommended that health care providers incorporate vaccination needs assessment, recommendation, and offer of vaccination into every clinical encounter with adult patients to improve vaccination rates and to narrow the widening racial/ethnic disparities in vaccination coverage (4,5).
The NHIS collects information about the health and health care of the noninstitutionalized U.S. civilian population using nationally representative samples. In-person interviews are conducted by the U.S. Census Bureau for CDC's National Center for Health Statistics. Questions about receipt of vaccinations recommended for adults are asked of one randomly selected adult within each family in the household. The presence of selected high-risk conditions, § as defined by ACIP for pneumococcal disease, was determined by responses to questions in the NHIS (2). Comprehensive information on all high-risk conditions for hepatitis B or A were not collected in the 2013 NHIS. Analyses were conducted to estimate age at first dose of HPV vaccination using data being collected in the NHIS for the first time starting in 2013. The final sample adult component response rate for the 2013 NHIS was 61.2%. Weighted data ¶ were used to produce national vaccination coverage estimates. Point estimates and estimates of corresponding variances were calculated using statistical software to account for the complex sample design. Statistical significance was defined as p<0.05.
See    Abbreviations: CI = confidence interval; HPV = human papillomavirus. * Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema, chronic obstructive pulmonary disease, coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; had been told by a doctor or other health professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months; had an asthma episode or attack during the preceding 12 months; or were current smokers. Information on high-risk status for hepatitis B or A was not collected in 2013. † Race/ethnicity was categorized as follows: Hispanic, black, white, Asian and "other. " In this report, persons identified as Hispanic might be of any race. Persons identified as black, white, Asian, or other race are non-Hispanic. "Other" includes American Indian/Alaska Native and multiple race. The five racial/ethnic categories are mutually exclusive. § Respondents were asked if they had ever had a pneumonia shot. ¶ p<0.05 by t-test for comparisons, with non-Hispanic white as the reference. ** p<0.05 by t-test test for comparisons between 2013 and 2012 within each level of each characteristic. † † Respondents were asked if they had received a tetanus shot in the past 10 years. Vaccinated respondents included adults who received tetanusdiphtheria toxoid (Td) during the past 10 years, or tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during 2005-2013. § § Respondents who had received a tetanus shot in the past 10 years were asked if their most recent shot was given in 2005 or later. Respondents who had received a tetanus shot since 2005 were asked if they were told that their most recent tetanus shot included the pertussis or whooping cough vaccine. Among 34,227 respondents aged ≥19 years, those without a "yes" or no" classification for tetanus vaccination status within the preceding 10 years (n = 1,780 [ and if yes, were asked how many shots were received. † † † p<0.05 by t-test for comparisons between persons who had traveled outside the United States to countries other than Europe, Japan, Australia, New Zealand, or Canada since 1995, and persons who had not traveled outside the United States to these areas since 1995. § § § Respondents were asked if they had ever received the hepatitis B vaccine, and if yes, if they had received ≥3 doses or <3 doses. ¶ ¶ ¶ Respondents were asked if they had ever received a shingles vaccine. **** Respondents were asked if they had ever received the HPV shot or cervical cancer vaccine.

Tetanus Vaccination Coverage
In 2013, the proportion of adults reporting having received any tetanus toxoid-containing vaccination during the past 10 years was 62.9% for adults aged 19-49 years, 64.0% for adults aged 50-64 years, and 56.4% for adults aged ≥65 years ( Table 1). The proportion of adults receiving tetanus vaccination during the past 10 years across all age groups did not change compared with 2012 (1). Whites had higher coverage across all age groups compared with blacks, Hispanics, and Asians.
Among adults aged ≥19 years for whom Tdap vaccination specifically could be assessed (including adults aged ≥65 years), overall reported coverage was 17.2%, a 2.9 percentage point increase compared with 2012 ( Among adults aged ≥19 years who received a tetanus vaccination and reported they knew what type of tetanus vaccine they received, HCP were more likely to report receipt of Tdap (76.9%) than were non-HCP (66.5%) ( Table 2).

Hepatitis A Vaccination Coverage
In 2013, reported hepatitis A vaccination coverage (≥2 doses) among adults was 9.0% for adults aged ≥19 years, 12.3% among adults aged 19-49 years, and 5.4% among adults aged ≥50 years, similar to the estimates for 2012 (Table 1). Among adults aged 19-49 years, coverage was higher for Asians (16.1%) than for whites (12.6%), but coverage for Hispanics (10.6%) was lower than for whites. Vaccination coverage was higher among adults aged ≥19 years who had traveled outside the United States since 1995 to a country where hepatitis A Abbreviations: CI = confidence interval; HCP = health care personnel. * Calculated by dividing number of respondents who reported receiving Tdap by the sum of those who reported receiving Tdap and those who reported receiving other tetanus vaccination; respondents who reported that the doctor did not inform them of the vaccine type they received and those who could not recall the vaccine type were excluded. † Adults were classified as HCP if they reported they currently volunteer or work in a hospital, medical clinic, doctor's office, dentist's office, nursing home, or some other health care facility, including part-time and unpaid work in a health care facility, as well as professional nursing care provided in the home. § p<0.05 by t-test for comparisons between HCP and non-HCP.

Herpes Zoster Vaccination Coverage
In 2013, 24.2% of adults aged ≥60 years reported receiving herpes zoster vaccination to prevent shingles, an increase from the 20.1% reported in 2012 (Table 1). Whites aged ≥60 years had higher herpes zoster vaccination coverage (27.4%) compared with blacks (10.7%) and Hispanics (9.5%).  Among women aged 19-26 years, 1.0% reported receiving the first dose of HPV vaccine at age 8-10 years, 2.0% at age 11-12 years, 53.4% at age 13-17 years, 15.9% at age 18 years, and 27.6% at age 19-26 years. Among males aged 19-26 years, 9.7% reported receiving the first dose of HPV vaccine at age 8-10 years, 8.8% at age 11-12 years, 37.0% at age 13-17 years, 18.1% at age 18 years, and 26.3% at age 19-26 years. Among respondents aged 19-26 years, the difference between age reported at time of interview and age respondents indicated the first dose of HPV vaccine was received was ≥9 years for 5% of women and 23.8% of males. This would imply receipt of vaccination in 2004 or earlier, before HPV vaccine was licensed for use in 2006.

Discussion
In 2013, estimated adult vaccination coverage in the United States for diseases other than influenza was similar to 2012, except for modest increases in Tdap vaccination for adults aged ≥19 years, herpes zoster vaccination among adults aged ≥60 years, and HPV vaccination among males aged 19-26 years, with no improvements in coverage for the other vaccines routinely recommended for adults. Vaccination coverage estimates for the three vaccines in this report that are included in Healthy People 2020 (pneumococcal, herpes zoster, and hepatitis B [for HCP] vaccines) are below the respective target levels of 90% for persons aged ≥65 years and 60% for persons aged 18-64 years at high risk (pneumococcal vaccine [objectives IID 13.1 and IID 13.2, respectively]), 30% for persons aged ≥60 years (herpes zoster vaccine [IID 14]), and 90% (hepatitis B vaccine for HCP [IID 15.3]). In addition, racial/ ethnic disparities in coverage persisted for all six vaccines in this report and widened for Tdap and herpes zoster vaccination, with higher coverage for whites compared with other groups. These data indicate little progress was made in improving adult vaccination coverage in the past year and highlight the need for continuing efforts to increase adult vaccination.
In August 2014, ACIP recommended routine use of PCV13 among adults aged ≥65 years. † † PCV13 should be administered in series with PPSV23, the vaccine currently recommended for adults aged ≥65 years. PPSV23 contains 12 serotypes in common with PCV13 and 11 additional serotypes. PCV13 vaccine has been demonstrated to reduce the risk for pneumococcal pneumonia, and both PCV13 and PPSV23 have been demonstrated to reduce the risk for invasive pneumococcal infections (6). Given the high proportion of invasive pneumococcal disease caused by serotypes unique to PPSV23, broader protection is expected to be provided through use of both PCV13 and PPSV23 in series. Adults who have already received PPSV23 and are recommended to receive PCV13 should receive PCV13 at lease 1 year after PPSV23 vaccine. The 2013 NHIS did not estimate the proportion of pneumococcal vaccinations by type (PCV13 versus PPSV23). The overall pneumococcal vaccination estimates in this report includes respondents who might have received PCV13 or PPSV23.
In 2012, ACIP updated the adult Tdap vaccination recommendation to include all adults aged ≥19 years who have not yet received a dose of Tdap, including those aged ≥65 years (6). Tdap, when indicated, should be administered regardless of interval since the last Td vaccination. Although there was a modest increase in overall Tdap vaccination of adults, coverage remained low for all age groups and among adults living with an infant aged <1 year. Health care providers should not miss an opportunity to vaccinate adults aged ≥19 years who have not received Tdap previously.
In December 2011, ACIP recommended that all previously unvaccinated adults aged 19-59 years with diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made, and that unvaccinated adults aged ≥60 years with diabetes may be vaccinated at the discretion of the treating clinician after assessing their risk and the likelihood of an adequate immune response to vaccination (6). Hepatitis B vaccination coverage in 2013 among persons with diabetes remained similar to estimates obtained before this recommendation and highlights the need to improve awareness of increased risk for contracting acute hepatitis B among persons with diabetes and to increase hepatitis B vaccination in this population.
ACIP recommends herpes zoster vaccination for adults aged ≥60 years. § § Herpes zoster vaccination coverage increased in 2013 compared with 2012, with the 2013 estimate 6 percentage points below the Healthy People 2020 target of 30%. Shortages of herpes zoster vaccine that might have contributed to lower coverage during the first years after licensure appear to have been resolved in 2012. The cost of herpes zoster vaccine and billing challenges might pose barriers for some patients and providers. ¶ ¶ † † Additional information on use of PCV13 among adults aged ≥65 years available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4. htm?s_cid=mm6337a4_w. § § Additional information on herpes zoster vaccination for adults aged ≥60 years available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6333a3. htm?s_cid=mm6333a3_w. ¶ ¶ Additional information on barriers to herpes zoster vaccination available at http://www.gao.gov/products/GAO-12-61 and http://www.gao.gov/ assets/590/587009.pdf.
Although the percentage of age-eligible females who reported having received HPV vaccine increased steadily from 2009 to 2012, coverage did not increase further in 2013 and remained low. ACIP recommends routine vaccination of adolescent girls and boys at ages 11 or 12 years and catch-up vaccination for females aged 13-26 years who have not been previously vaccinated (6). ACIP recommends vaccination for males aged 13-21 years who have not been vaccinated previously or who have not completed the 3-dose series; males aged 22-26 years may be vaccinated (6). Data on age at first dose of HPV vaccination of adults was collected for the first time in 2013. The findings in this report indicate that most female and male respondents in the NHIS reported receiving the first dose of HPV vaccine at age ≥13 years (i.e., at ages 13-18 years). Only 2% of females and about 9% of males reported receiving the first dose at the target ages of 11 or 12 years. Some respondents also indicated the first HPV vaccination dose was received before HPV vaccine was licensed for use in 2006 suggesting inaccurate recall. In 2013, white women reported higher HPV coverage than black, Hispanic, or Asian women. The finding for Hispanic women is in contrast to data on HPV vaccination of adolescent girls aged 13-17 years reported in the 2013 National Immunization Survey -Teen (NIS-Teen) (7). In the 2013 NIS-Teen, among females, ≥1, ≥2, and ≥3 HPV dose coverage was higher among Hispanic compared with white adolescents. HPV vaccination coverage for ≥1 and ≥2 doses was higher for females living below poverty level compared with those living at or above the poverty level. The higher coverage in NIS-Teen among Hispanic females and those living below poverty level might be partly attributable to the continued effectiveness of the Vaccines for Children program, which provides recommended vaccines at no cost to eligible children through age 18 years (7). Although vaccination coverage among persons aged 13-17 years has increased since a licensed HPV vaccine has been available and recommended by ACIP, many adolescent and young adult females remain unvaccinated and vulnerable to develop cancers that HPV vaccines can prevent. Until HPV vaccination increases among adolescents, a high proportion of young women eligible for HPV vaccination will be expected. Results from studies of the cost-effectiveness of HPV vaccination of young women have suggested that catch-up vaccination could reduce the amount of time needed to achieve population level impacts of vaccination (8,9). Findings from initial studies of vaccination impact in settings where catch-up vaccination programs were successful in achieving high coverage rates among young women are consistent with these cost-effectiveness studies (9). Continued efforts are needed to ensure coverage among members of the primary target group for HPV vaccine, girls and boys aged 11 or 12 years, and among all racial/ethnic groups. Efforts are also needed to improve catch-up vaccination among those who have not started or completed their vaccinations.
The findings in this report are subject to at least five limitations. First, the NHIS sample excludes persons in the military and those residing in institutions, which might result in underestimation or overestimation of vaccination coverage levels. Second, the response rate was 61.2%. A low response rate can result in nonresponse bias if respondents and nonrespondents differ in their vaccination rates. Third, the determination of vaccination status and identification of high-risk conditions in the NHIS were not validated by medical records. Fourth, self-report of vaccination might be subject to recall bias. Adult self-reported vaccination status has been shown to be sensitive for all six vaccines in this report and specific for all except tetanus vaccination (10). Finally, the Tdap estimate is subject to considerable uncertainty. Respondents who reported a tetanus vaccination but were unable to say whether Td or Tdap was used during 2005-2013 were excluded from estimations of Tdap coverage, creating a potential for bias. Sensitivity calculations were conducted to assess the magnitude of potential bias. Depending on what proportion of excluded respondents actually received Tdap, actual Tdap coverage could fall within the range of 13.0%-42.4% for adults aged 19-64 years and 8.7%-35.3% for adults aged ≥65 years. Comparisons of Tdap coverage across years within subgroups might be affected by bias resulting from excluding persons who did not report the type of tetanus vaccine they received.
What is already known on this topic?
During 2008-2012, National Health Interview Survey (NHIS) data indicated that coverage with routinely recommended vaccinations among U.S. adults aged ≥19 years remained low.
What is added by this report?
Based on 2013 NHIS data, compared with 2012, modest gains occurred in tetanus and diphtheria toxoid with acellular pertussis vaccine (Tdap) vaccination among adults aged ≥19 years (a 2.9 percentage point increase to 17.2%), herpes zoster vaccination among adults aged ≥60 years (a 4.1 percentage point increase to 24.2%), and human papillomavirus vaccination coverage among males aged 19-26 years (a 3.6 percentage point increase to 5.9%). Coverage for other vaccines and risk groups did not improve, and racial/ethnic disparities persisted for routinely recommended adult vaccines. Coverage for all vaccines for adults remained low.
What are the implications for public health practice?
Wider use of practices shown to improve adult vaccination is needed, including assessment of patients' vaccination needs by health care providers and routine recommendation and offer of needed vaccines to adults, implementing reminder-recall systems, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members.
Vaccination coverage levels among adults are low. Improvement in adult vaccination is needed to reduce the health consequences of vaccine-preventable diseases among adults. Successful vaccination programs combine 1) education of potential vaccine recipients and publicity to promote vaccination, 2) increased access to vaccination services in health care settings, and 3) use of practices shown to improve vaccination coverage, including reminder-recall systems, efforts to remove administrative and financial barriers to vaccination, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members (4). Health care provider recommendations for vaccination are associated with patients' receipt of vaccines.*** Routine assessment of adult patient vaccination needs, recommendation, and offer of needed vaccinations for adults should be incorporated into routine clinical care of adults (4,5). The adult immunization schedule (2), updated annually, provides current recommendations for vaccinating adults and a ready resource for persons who provide health care services for adults in various settings.